HISTORY TAKINGHISTORY TAKINGDR.H.N.SARKERDR.H.N.SARKER

MBBS,FCPS,MACP(USA),MBBS,FCPS,MACP(USA),

MRCP(LONDON).MRCP(LONDON).

Case history- Mr.Rahman,50 yrs has Case history- Mr.Rahman,50 yrs has been presented to you with swelling been presented to you with swelling of the abdomen for 3 months.of the abdomen for 3 months.

C/C. swelling of the abdomen for 3 C/C. swelling of the abdomen for 3 months.months.

Acquiring the historyAcquiring the history

Before initiating the history Before initiating the history taking, think for a few seconds and taking, think for a few seconds and make a list of differential diagnosis in make a list of differential diagnosis in your mind. your mind.

Such as in this case the abdominal Such as in this case the abdominal swelling may be due to 5 Fs- fat swelling may be due to 5 Fs- fat (obesity), fluid (ascites), flatus (obesity), fluid (ascites), flatus (gaseous distention), faeces and (gaseous distention), faeces and fetus (not in this case). fetus (not in this case).

Most common cause of abdominal Most common cause of abdominal swelling is ascites, so the differential swelling is ascites, so the differential diagnosis may be diagnosis may be

Cirrhosis of liverCirrhosis of liver

Congestive cardiac failureCongestive cardiac failure

Abdominal malignancyAbdominal malignancy

Abdominal tuberculosisAbdominal tuberculosis

Nephritic syndromeNephritic syndrome

Presenting complaint:Presenting complaint:

Begin with an open question, without Begin with an open question, without focusing on the abdominal swelling. `I focusing on the abdominal swelling. `I understand from you that you haven’t understand from you that you haven’t been feeling so well over recent months-been feeling so well over recent months-when did you last feel your health was when did you last feel your health was normal?; How have you been feeling normal?; How have you been feeling since?; Can you tell me a little more about since?; Can you tell me a little more about that....? that....?

History of presenting complaint:History of presenting complaint:

Ask about Ask about the details of the the details of the abdominal swellingabdominal swelling particularly- particularly-• the time span-how long is the swelling?the time span-how long is the swelling?• is the swelling progressing? is the swelling progressing? • whether the swelling is generalized or whether the swelling is generalized or

focal?focal?• is there any associated pain or is there any associated pain or

discomfort?discomfort?• Is there any leg swelling?Is there any leg swelling?

Other gastrointestinal symptomsOther gastrointestinal symptoms indicating the cause- e.g.indicating the cause- e.g.• Have you vomited blood Have you vomited blood

(haematemesis)?- liver cirrhosis, ca-(haematemesis)?- liver cirrhosis, ca-stomach.stomach.

• Have you passed black tarry stool Have you passed black tarry stool ( melaena)?- liver cirrhosis, ca-stomach ( melaena)?- liver cirrhosis, ca-stomach and ca colon.and ca colon.

• Do you ever have any jaundice?- liver Do you ever have any jaundice?- liver cirrhosis cirrhosis

• Do you notice recent change in your Do you notice recent change in your bowel habit?- ca colon and abdominal bowel habit?- ca colon and abdominal tuberculosis tuberculosis

• Do you notice any nodular swelling in Do you notice any nodular swelling in the body?-lymphoma, malignancy and the body?-lymphoma, malignancy and disseminated tuberculosisdisseminated tuberculosis

systemic symptomssystemic symptoms, e.g., e.g.• Loss of weight and appetite- Loss of weight and appetite-

tuberculosis, malignancy.tuberculosis, malignancy.• Fever- lymphoma, tuberculosis and Fever- lymphoma, tuberculosis and

malignancy. malignancy. • Breathlessness as a result of the ascites Breathlessness as a result of the ascites

and congestive cardiac failure.and congestive cardiac failure.

other causes of ascitesother causes of ascites, e.g. , e.g. • symptoms suggestive of acute or symptoms suggestive of acute or

chronic pancreatitis, chronic pancreatitis, • intra-abdominal sepsis/ infection, intra-abdominal sepsis/ infection, • hepatic vein thrombosis, hepatic vein thrombosis, • hypothyroidism.hypothyroidism.

System review-System review-• Cough, haemoptysis- tuberculosis, Cough, haemoptysis- tuberculosis,

malignancy.malignancy.• Chest pain,palpitation- congestive Chest pain,palpitation- congestive

cardiac failure.cardiac failure.• Altered sleep rhythm,alteration of Altered sleep rhythm,alteration of

conscious level - liver cirrhosis conscious level - liver cirrhosis

Past medical history-Past medical history-• H/o viral hepatitis-- liver cirrhosis H/o viral hepatitis-- liver cirrhosis • Past history of TB, contact with TB pt in Past history of TB, contact with TB pt in

home and workplacehome and workplace• History of IHD, HTN,DM.History of IHD, HTN,DM.• History of renal disease.History of renal disease.

Relevant family history:Relevant family history:• Ask about a family history of liver Ask about a family history of liver

disease(Haemachromatosis, Wilson’s disease(Haemachromatosis, Wilson’s disease), hepatitis(Hepatitis B may be disease), hepatitis(Hepatitis B may be vertically transmitted). vertically transmitted).

• Ask about a family history of Ask about a family history of tuberculosis, colon cancer.tuberculosis, colon cancer.

Drug history:Drug history:• Ask about about current and previous Ask about about current and previous

medications whice may liver disease e.g. MTX medications whice may liver disease e.g. MTX or nephritic syndrome e.g. ACEi.or nephritic syndrome e.g. ACEi.

Social history:Social history:• Alcohol historyAlcohol history• Smoking historySmoking history• Sexual historySexual history• Occupational historyOccupational history

Vaccination history:Vaccination history: Hepatitis B vaccinationHepatitis B vaccination

Physical examination-Physical examination-

Do the Do the general examinationgeneral examination with special with special attention to-attention to-• Appearance- hepatic facies- liver cirrhosis Appearance- hepatic facies- liver cirrhosis • Puffy face-nephrotic syndromePuffy face-nephrotic syndrome• AnaemiaAnaemia• Cutaneous stigmata of liver disease- Cutaneous stigmata of liver disease-

leuconychia, clubbing, palmar erythema, leuconychia, clubbing, palmar erythema, depuytren’s contracture, spider navi, tattoo depuytren’s contracture, spider navi, tattoo mark, loss of hair, gynaecomastia. mark, loss of hair, gynaecomastia.

• LymphadenopathyLymphadenopathy• OdemaOdema

Systemic examination-Systemic examination-

Abdomen-Abdomen- InspectionInspection-distended abdomen, -distended abdomen,

flanks are full, umbilicus is centrally flanks are full, umbilicus is centrally placed and everted. May have recti placed and everted. May have recti diverication. May have engorged diverication. May have engorged veins with normal direction of flow.veins with normal direction of flow.

Palpation- Palpation- fluid thrill may be fluid thrill may be present. There may be present. There may be splenomegaly, hepatomegaly and splenomegaly, hepatomegaly and abdominal lymphadenopathy.abdominal lymphadenopathy.

Percussion-Percussion-shifting dullness is shifting dullness is present.present.

Auscultation-Auscultation-bowel sound normal.bowel sound normal.

CVS- CVS- pulse, BP, JVP and precordiumpulse, BP, JVP and precordium

Respiratory- Respiratory- evidence of evidence of tuberculosis, pl.effusion.tuberculosis, pl.effusion.

NS-NS- confusion, disorientation, confusion, disorientation, apraxia, flapping tremor and planter apraxia, flapping tremor and planter response. response.

Salient featureSalient feature

Mr.Rahman,50 yrs old farmer nonsmoker, Mr.Rahman,50 yrs old farmer nonsmoker,

nonalcoholic, nondiabetic,nonhypertensive nonalcoholic, nondiabetic,nonhypertensive

hailing from maderipur has been admitted hailing from maderipur has been admitted

into this hospital with gradual swelling of into this hospital with gradual swelling of

abdomen for 3 months with little abdomen for 3 months with little

discomfort but no pain. discomfort but no pain.

The abdominal swelling is not The abdominal swelling is not associated with dependent odema, associated with dependent odema, facial puffiness, breathlessness, facial puffiness, breathlessness, haematemesis, maelena, weight loss, haematemesis, maelena, weight loss, fever. fever.

The pt gives no history of chest pain, The pt gives no history of chest pain, palpitation but noticed change of palpitation but noticed change of sleep pattern. sleep pattern.

The pt. has no past history of The pt. has no past history of tuberculosis, heart disease, tuberculosis, heart disease, hypertention, renal disease but he hypertention, renal disease but he suffered from viral hepatitis 7 yrs suffered from viral hepatitis 7 yrs back but he does not know viral back but he does not know viral status. No significant family history, status. No significant family history, drug history and social history. drug history and social history.

On examination pt. has hepatic On examination pt. has hepatic facies, spider navi (5 in number), facies, spider navi (5 in number), gynaecomastia and testicular gynaecomastia and testicular atrophy but no other positive findings atrophy but no other positive findings on G/E. Abdominal examination on G/E. Abdominal examination reveals ascites and splenomegaly.reveals ascites and splenomegaly.

So my provisional diagnosis is CLD. So my provisional diagnosis is CLD.